Killing Obamacare Softly

Enrollment assistance in Miami. The Trump administration has cut the enrollment period in half.CreditCreditJoe Raedle/Getty Images

Unable — at least so far — to kill the Affordable Care Act outright, the Trump administration has conducted a sustained war of attrition designed to inflict fatal damage on Obamacare.

This war, often operating below the radar, entails the use of a quintessentially conservative strategy, and the cooperation of Congressional Republicans. In a way, it’s pretty simple: You cut the budget, impose debilitating regulations, track the subsequent missteps and then attack the program as a failure.

The political opportunism behind the Republicans’ determination to undo legislation that makes federally financed health care more broadly available has deep roots.

it will relegitimize middle-class dependence for “security” on government spending and regulation. It will revive the reputation of the party that spends and regulates, the Democrats, as the generous protector of middle-class interests. And it will at the same time strike a punishing blow against Republican claims to defend the middle class by restraining government.

Sound familiar? The Kristol memo captures the reasoning and the philosophy behind the many covert (and overt) Republican attempts to eviscerate Obamacare.

“There’s a clear pattern of the administration trying to undermine and sabotage the Affordable Care Act,” Elizabeth Hagan, an associate director at Families USA, a liberal advocacy group, told The Associated Press. “It’s not letting the law fail, it’s making the law fail.”

In an email, Sarah Lueck of the nonpartisan Center on Budget and Policy Priorities, explained that this “rule allows insurers in the individual market to offer plans with higher deductibles and out of pocket costs in 2018 than have been permitted previously.” Because of this, “the rule is likely to reduce the premium tax credit for many people.” A premium tax credit is a federal subsidy that consumers can use to lower their monthly health insurance payments.

A study the center conducted in February outlines the damage that this rule inflicts on Obamacare by reducing federal subsidies. It found that it would “raise premiums, out-of-pocket costs, or both for millions of moderate-income families.” In addition,

the rule would reduce the amount of health care that marketplace plans have to cover. That would allow individual-market insurers to offer plans with higher deductibles and other out-of-pocket costs than they can now sell through the marketplaces.

Most important, according to the center’s analysis, is the covert aspect of the rule which has

the hidden impact of reducing the Affordable Care Act’s premium tax credits, which help moderate-income marketplace consumers afford health care. As a result, the rule would force millions of families to choose between higher premiums or worse coverage.

The attacks began on day one, March 23, 2010, when the A.C.A. was signed into law. Fourteen state Attorneys General, 13 of them Republicans, filed suit challenging the constitutionality of the mandate requiring individuals to buy health care coverage. The sole Democratic Attorney General involved, Buddy Caldwell of Louisiana, switched into the Republican Party in 2011.

On June 28, 2012, the Supreme Court affirmed the constitutionality of the individual mandate but in a blow to the program, Norris wrote, it also

ruled that the federal government could not withhold Medicaid funding from states that did not expand Medicaid. This had the effect of making the ACA’s Medicaid expansion optional, which has, in turn, hobbled the ACA’s progress in many states.

The assault on the program has continued unabated, including in this recent tweet by Tom Price, the secretary of health and human services:

Perhaps most significant among Republican sabotage efforts was the decision by House Republicans to file suit in 2014 challenging the constitutionality of “cost sharing reductions” — payments made by the federal government to insurance companies in order to lower premiums for those making less than 250 percent of poverty income. It is these payments that make health care affordable for moderate-to-low-income Americans.

The suit went before Rosemary Collyer, a George W. Bush appointee on the Federal District Court in Washington, D.C. In May, 2016, Collyer ruled in favor of the House Republicans, declaring that although Congress had authorized the subsidies, there had never been a specific appropriation. Collyer did allow the federal government to continue making the payments while the decision is under appeal.

Trump has warned that he may drop the appeal and end the subsidies — both of which he can do unilaterally — to deliver what Politico called “an immediate and fatal blow to the Obamacare marketplaces.”

“The best thing politically is to let Obamacare explode,” Trump told The Washington Post on March 24. The program is “totally the property of the Democrats” so that “when people get a 200 percent increase next year or a 100 percent or 70 percent, that’s their fault.”

Survey data suggests that Trump may be wrong about whom the public would blame.

The Kaiser Family Foundation tracking poll asked voters in June whether Trump and Republicans or President Obama and Democrats would be “responsible for any problems with” the Affordable Care Act “going forward?”

By nearly 2-1 voters said Trump and Republicans in Congress would be responsible, 59-30, a view shared even by Republicans, 56-35.

For the moment, the Trump administration has chosen to keep the subsidies in a legal limbo, putting off a decision on whether to persist with the appeal and continue paying out the subsidies.

On June 21, for instance, Anthem, one of the largest Obamacare providers, announced that in 2018 it would pull out of markets in Wisconsin and Indiana, following a similar announcement two weeks earlier that it would drop coverage in Ohio.

Anthem declared that

planning and pricing for ACA-compliant health plans has become increasingly difficult due to a shrinking and deteriorating individual market, as well as continual changes and uncertainty in federal operations, rules and guidance, including cost-sharing reduction subsidies and the restoration of taxes on fully insured coverage.

On cue, Paul Ryan, the House Speaker — and, long before Trump took office, a leader of the efforts to undercut Obamacare — declared:

Obamacare is clearly collapsing, and we have to step in before more families get hurt. We are on a rescue mission to replace this collapsing law with a better system so that people have lower costs, more choices, and real peace of mind. We need to get this done.

Needless to say, a better, cheaper system failed to materialize.

There is no stronger voice maligning Obamacare than Tom Price. His Twitter feed launches one attack after another.

He retweeted this @FoxBusiness tweet:

The Health and Human Services Department has the legal responsibility for administering the Affordable Care Act, but under Price the department serves as a key administration weapon in efforts to discredit the A.C.A.

The department has produced 12 videos intensely hostile to Obamacare. All are available to the public on YouTube. In an email to me, Tim Gronniger, deputy chief of staff and the director of delivery system reform at the Centers for Medicare and Medicaid Services during the Obama administration, characterized one of the videos as “shot through with misinformation” and “major falsehoods.”

In the Senate this week, new Republican bids to ax Obamacare have failed, with as many as seven Republicans joining a unified Senate Democratic caucus to reject proposal after proposal.

The Republican defections have embittered Trump. At 7:13 a.m. on Wednesday, the president tweeted:

In the event of ultimate failure on the Senate floor, Trump and the Republican Congress will keep up their subterfuge and continue their underhanded way of making and unmaking policy.

Whether the A.C.A. can survive the administration’s strategy of death by 1,000 cuts, whether any plan delivering quality health care at an affordable price could survive a relentless assault like this, remains an open question.